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Strobel RJ, Krebs ED, Cunningham M, Chaudry B, Mehaffey JH, Sarosiek B, Durieux M, Dunn L, Naik BI, Blank RS, Martin LW. Enhanced Recovery Protocol Associated With Decreased 3-Month Opioid Use After Thoracic Surgery. Ann Thorac Surg 2023; 115:241-247. [PMID: 35779605 DOI: 10.1016/j.athoracsur.2022.05.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/26/2022] [Accepted: 05/25/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Enhanced recovery protocols (ERPs) have been shown to decrease inhospital opioid use after thoracic surgery. However, the impact on opioid use after discharge has not been reported. We hypothesized that prolonged opioid use would decrease after implementation of a comprehensive ERP. METHODS Records from all patients undergoing elective pulmonary, pleural, and mediastinal operations at a single institution (2015-2018) were abstracted from a prospective ERP database and The Society of Thoracic Surgeons institutional database. Records were reviewed for documentation of opioid use at 3-month and 6-month postoperative visits. Patients with preoperative chronic opioid use were excluded. Univariate analysis compared patients with and patients without 3-month opioid use, and a multivariable logistic regression evaluated independent predictors of prolonged opioid use. RESULTS A total of 499 patients was included: 160 pre-ERP, and 339 post-ERP. Three-month opioid use rates were decreased after implementation of an ERP (44% vs 30%, P = .01); 6-month opioid use rates were not significantly different (25% vs 18%, P = .10). Univariate analysis demonstrated increased 3-month opioid use rates among patients with preoperative tobacco use (38% vs 27%, P = .05) and chronic pain disorder (88% vs 32%, P < .01), with no impact from surgical incision (video-assisted thoracoscopic surgery 33%; open 37%, P = .49). On multivariable analysis, participation in an ERP was independently associated with decreased opioid use at 3 months (odds ratio 0.53; 95% CI, 0.31-0.89; P = .02). CONCLUSIONS There is a high burden of prolonged opioid use after elective thoracic surgery. Participation in a comprehensive ERP is associated with decreased opioid use 3 months postoperatively.
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Affiliation(s)
- Raymond J Strobel
- Divisions of Thoracic and Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Elizabeth D Krebs
- Divisions of Thoracic and Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Michaela Cunningham
- Divisions of Thoracic and Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Bakhtiar Chaudry
- Divisions of Thoracic and Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Divisions of Thoracic and Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Bethany Sarosiek
- Divisions of Thoracic and Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Marcel Durieux
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Lauren Dunn
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Randal S Blank
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Linda W Martin
- Divisions of Thoracic and Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
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Drawbert HE, Hey MT, Tarrazzi F, Block M, Razi SS. Early discharge on postoperative day 1 following lobectomy for stage I non-small-cell lung cancer is safe in high-volume surgical centres: a national cancer database analysis. Eur J Cardiothorac Surg 2021; 61:1022-1029. [PMID: 34849695 DOI: 10.1093/ejcts/ezab490] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 08/17/2021] [Accepted: 08/28/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Shortening hospital length of stay after lobectomy for stage I non-small-cell lung cancer (NSCLC) remains a challenge, and the literature regarding factors associated with safe early discharge is limited. We sought to evaluate the safety of postoperative day (POD) 1 discharge after lobectomy and its correlation with institutional caseload using the National Cancer Database, jointly sponsored by the American College of Surgeons and the American Cancer Society. METHODS We identified patients with stage I NSCLC (tumour ≤4 cm, clinical N0, M0) in the National Cancer Database who underwent lobectomy from 2010 to 2015. Hospital surgical volume was assigned based on total surgical volume for lung cancer. The cohort was divided into 2 groups: POD 1 discharge [length of stay (LOS) ≤ 1] and the standard discharge (LOS > 1). Outcome variables were compared in propensity matched cohorts, and the multivariable regression model was created to assess factors associated with LOS ≤ 1 and the occurrence of adverse events (unplanned readmissions, 30- and 90-day deaths). RESULTS A total of 52 830 patients underwent lobectomy for stage I NSCLC across 1231 treating facilities; 3879 (7.3%) patients were discharged on day 1 (LOS ≤ 1), whereas 48 951 (92.7%) were discharged after day 1 (LOS > 1). Factors associated with LOS ≤ 1 included male sex, higher socioeconomic status, right middle lobectomy, minimally invasive surgery and high-volume centres. The risk of adverse events was higher for LOS ≤ 1 in low [odds ratio (OR): 1.913, 95% confidence interval (CI) 1.448-2.527; P < 0.001] and median quartiles (OR: 2.258; 95% CI 1.881-2.711; P < 0.001), but equivalent in high-volume centres (OR: 0.871, 95% CI 0.556-1.364; P = 0.54). CONCLUSIONS The safety and efficacy of early discharge on POD 1 following lobectomy are associated with lung cancer surgical volume. Implementation of 'enhanced recovery' protocols is likely related to safe early discharges from high-volume centres.
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Affiliation(s)
- Hans E Drawbert
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Matthew T Hey
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Francisco Tarrazzi
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Mark Block
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Syed S Razi
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.,Division of Thoracic Surgery, Memorial Healthcare System, Pembroke Pines, FL, USA
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3
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Kodia K, Stephens-McDonnough JA, Alnajar A, Villamizar NR, Nguyen DM. Implementation of an enhanced recovery after thoracic surgery care pathway for thoracotomy patients-achieving better pain control with less (schedule II) opioid utilization. J Thorac Dis 2021; 13:3948-3959. [PMID: 34422325 PMCID: PMC8339763 DOI: 10.21037/jtd-21-552] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/20/2021] [Indexed: 01/22/2023]
Abstract
Background Enhanced recovery after surgery protocols incorporate evidence-based practices of pre-, intra- and post-operative care to achieve the most optimal surgical outcome, safe on-time discharge, and surgical cost efficiency. Such protocols have been adapted for specialty-specific needs and are implemented by a variety of surgical disciplines including general thoracic surgery. This study aims to evaluate the impact of our enhanced recovery after thoracic surgery (ERATS) protocol on postoperative outcomes, pain, and opioid utilization following thoracotomy. Methods This is a retrospective analysis of patients undergoing elective resection of intrathoracic neoplasms via posterolateral thoracotomy between 1/1/2016 and 3/1/2020. Our enhanced recovery protocol, with a focus on multimodal pain management (opioid-sparing analgesics, infiltration of local anesthetics into intercostal spaces and surgical wounds, and elimination of thoracic epidural analgesia) was initiated on 2/1/2018. Demographics, clinicopathology data, subjective pain levels, peri-operative outcomes, in-hospital and post-discharge opioid utilization were obtained from the electronic medical record. Results A total of 98 patients (43 pre- and 55 post-protocol implementation) were included in this study. There was no difference in perioperative outcomes or percentage of opioid utilization between the two cohorts. The enhanced recovery group had significantly less acute pain. A significant reduction of in-hospital potent schedule II opioid use was noted following ERATS implementation [average MME: 10.5 (3.5–16.5) (ERATS) vs. 19.5 (12.6–36.0) (pre-ERATS), P<0.0001]. More importantly, a drastic reduction of total and schedule II opioids dispensed at discharge was noted in the ERATS group [total MME: 150 (100.0–330.0) vs. 800.0 (450.0–975.0), P<0.0001 and schedule II MME: 90.0 (0–242.2) vs. 800.0 (450.0–975.0), P<0.0001; ERATS vs. pre-ERATS respectively]. A shorter hospital stay (median difference of 1 day, P=0.0012 and a mean difference of 2.4 days, P=0.0054) was observed in the enhanced recovery group. Conclusions Implementation of an enhanced recovery protocol for thoracotomy patients is safe and associated with elimination of thoracic epidural analgesia, decreased postoperative pain, shorter hospitalization, drastic reduction of post-discharge opioid dispensed and decreased dependence on addiction-prone schedule II narcotics.
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Affiliation(s)
- Karishma Kodia
- Thoracic Surgery Section, Division of Cardiothoracic Surgery, The DeWitt Daughtry Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Joy A Stephens-McDonnough
- Thoracic Surgery Section, Division of Cardiothoracic Surgery, The DeWitt Daughtry Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Ahmed Alnajar
- Thoracic Surgery Section, Division of Cardiothoracic Surgery, The DeWitt Daughtry Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Nestor R Villamizar
- Thoracic Surgery Section, Division of Cardiothoracic Surgery, The DeWitt Daughtry Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Dao M Nguyen
- Thoracic Surgery Section, Division of Cardiothoracic Surgery, The DeWitt Daughtry Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
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4
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Enhanced Recovery After Surgery Protocol Minimizes Intensive Care Unit Utilization and Improves Outcomes Following Pulmonary Resection. World J Surg 2021; 45:2955-2963. [PMID: 34350489 PMCID: PMC8336670 DOI: 10.1007/s00268-021-06259-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2021] [Indexed: 11/14/2022]
Abstract
Background Enhanced recovery after surgery (ERAS) protocols have been associated with improved postoperative outcomes but require further validation in thoracic surgery. This study evaluated outcomes of patients undergoing pulmonary resection before and after implementation of an ERAS protocol. Methods Electronic medical records were queried for all patients undergoing pulmonary resection between April 2017 and April 2019. Patients were grouped into pre- and post-ERAS cohorts based on dates of operation. The ERAS protocol prioritized early mobilization, limited invasive monitoring, euvolemia, and non-narcotic analgesia. Primary outcome measures included intensive care unit (ICU) utilization, postoperative pain metrics, and perioperative morbidity. Regression analyses were performed to identify predictors of morbidity. Subgroup analyses were performed by pulmonary risk profile and surgical approach. Results A total of 64 pre- and 67 post-ERAS patients were included in the study. ERAS implementation was associated with reduced postoperative ICU admission (pre: 65.6% vs. post: 19.4%, p < 0.0001), shorter ICU median length of stay (LOS) (pre: 1 vs. post: 0, p < 0.0001), and decreased opioid usage measured by median morphine milligram equivalents (pre: 40.5 vs. post: 20.0, p < 0.0001). Post-ERAS patients also reported lower visual analog scale (VAS) pain scores on postoperative days (POD) 1 and 2 (pre: 6.3/5.6 vs. post: 5.3/4.2, p = 0.04/0.01) as well as average VAS pain score over POD0-2 (pre: 6.2 vs. post: 5.2, p = 0.005). Conclusions Implementation of an ERAS protocol for pulmonary resection, which dictated reduced ICU admissions, did not increase major postoperative morbidity. Additionally, ERAS-enrolled patients reported improved postoperative pain control despite decreased opioid utilization. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-021-06259-1.
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5
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Manerikar A, Querrey M, Cerier E, Kim S, Odell DD, Pesce LL, Bharat A. Comparative Effectiveness of Surgical Approaches for Lung Cancer. J Surg Res 2021; 263:274-284. [PMID: 33309173 PMCID: PMC8169528 DOI: 10.1016/j.jss.2020.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/18/2020] [Accepted: 10/21/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND The magnitude of association and quality of evidence comparing surgical approaches for lung cancer resection has not been analyzed. This has resulted in conflicting information regarding the relative superiority of the different approaches and disparate opinions on the optimal surgical treatment. We reviewed and systematically analyzed all published data comparing near- (30-d) and long-term mortality for minimally invasive to open surgical approaches for lung cancer. METHODS Comprehensive search of EMBASE, MEDLINE, and the Cochrane Library, from January 2009 to August 2019, was performed to identify the studies and those that passed bias assessment were included in the analysis utilizing propensity score matching techniques. Meta-analysis was performed using random-effects and fixed-effects models. Risk of bias was assessed via the Newcastle-Ottawa Scale and the ROBINS-I tool. The study was registered in PROSPERO (CRD42020150923) prior to analysis. RESULTS Overall, 1382 publications were identified but 19 studies were included encompassing 47,054 patients after matching. Minimally invasive techniques were found to be superior with respect to near-term mortality in early and advanced-stage lung cancer (risk ratio 0.45, 95% confidence interval [CI] 0.21-0.95, I2 = 0%) as well as for elderly patients (odds ratio 0.45, 95% CI 0.31-0.65, I2 = 30%), but did not demonstrate benefit for high-risk patients (odds ratio 0.74, 95% CI 0.06-8.73, I2 = 78%). However, no difference was found in long-term survival. CONCLUSIONS We performed the first systematic review and meta-analysis to compare surgical approaches for lung cancer which indicated that minimally invasive techniques may be superior to thoracotomy in near-term mortality, but there is no difference in long-term outcomes.
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Affiliation(s)
- Adwaiy Manerikar
- Division of Thoracic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Melissa Querrey
- Division of Thoracic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Emily Cerier
- Division of Thoracic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Samuel Kim
- Division of Thoracic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David D Odell
- Division of Thoracic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lorenzo L Pesce
- Division of Thoracic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ankit Bharat
- Division of Thoracic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Liu CW, Page MG, Weinrib A, Wong D, Huang A, McRae K, Fiorellino J, Tamir D, Kahn M, Katznelson R, Ladha K, Abdallah F, Cypel M, Yasufuku K, Chan V, Parry M, Khan J, Katz J, Clarke H. Predictors of one year chronic post-surgical pain trajectories following thoracic surgery. J Anesth 2021; 35:505-514. [PMID: 34002257 DOI: 10.1007/s00540-021-02943-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 05/03/2021] [Indexed: 03/21/2023]
Abstract
PURPOSE Chronic post-surgical pain (CPSP) is a highly prevalent complication following thoracic surgery. This is a prospective cohort study that aims to describe the pain trajectories of patients undergoing thoracic surgery beginning preoperatively and up to 1 year after surgery METHODS: Two hundred and seventy nine patients undergoing elective thoracic surgery were enrolled. Participants filled out a preoperative questionnaire containing questions about their sociodemographic information, comorbidities as well as several psychological and pain-related statuses. They were then followed-up during their immediate postoperative period and at the three, six and 12 month time-points to track their postoperative pain, complications and pain-related outcomes. Growth mixture modeling was used to construct pain trajectories. RESULTS The first trajectory is characterized by 185 patients (78.1%) with mild pain intensity across the 12 month period. The second is characterized by 32 patients (7.5%) with moderate pain intensity immediately after surgery which decreases markedly by 3 months and remains low at the 12 month follow-up. The final trajectory is characterized by 20 patients (8.4%) with moderate pain intensity immediately after surgery which persists at 12 months. Patients with moderate to severe postoperative pain intensity were much more likely to develop CPSP compared to patients with mild pain intensity. Initial pain intensity levels immediately following surgery as well as levels of pain catastrophizing at baseline were predicting pain trajectory membership. None of the surgical or anesthetic-related variables were significantly associated with pain trajectory membership. CONCLUSION Patients who undergo thoracic surgery can have postoperative pain that follows one of the three different types of trajectories. Higher levels of immediate postoperative pain and preoperative pain catastrophizing were associated with moderately severe CPSP.
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Affiliation(s)
- Christopher W Liu
- Department of Pain Medicine, Singapore General Hospital, Outram, Singapore
| | - M Gabrielle Page
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Aliza Weinrib
- Pain Research Unit and Transitional Pain Service, Department of Anesthesia, Toronto General Hospital, Toronto, ON, Canada
| | - Dorothy Wong
- Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada
| | - Alexander Huang
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada
| | - Karen McRae
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada
| | - Joseph Fiorellino
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada
| | - Diana Tamir
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada
| | - Michael Kahn
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada
| | - Rita Katznelson
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada
| | - Karim Ladha
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
| | - Faraj Abdallah
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Marcelo Cypel
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Vincent Chan
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, Toronto, ON, Canada
| | - Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - James Khan
- Department of Anesthesiology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Joel Katz
- Department of Psychology, York University, Toronto, ON, Canada
| | - Hance Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada. .,Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada.
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7
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Liu SQ, Ma XB, Song WM, Li YF, Li N, Wang LN, Liu JY, Tao NN, Li SJ, Xu TT, Zhang QY, An QQ, Liang B, Li HC. Using a risk model for probability of cancer in pulmonary nodules. Thorac Cancer 2021; 12:1881-1889. [PMID: 33973725 PMCID: PMC8201526 DOI: 10.1111/1759-7714.13991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/19/2021] [Indexed: 12/24/2022] Open
Abstract
Background Considering the high morbidity and mortality of lung cancer and the high incidence of pulmonary nodules, clearly distinguishing benign from malignant lung nodules at an early stage is of great significance. However, determining the kind of lung nodule which is more prone to lung cancer remains a problem worldwide. Methods A total of 480 patients with pulmonary nodule data were collected from Shandong, China. We assessed the clinical characteristics and computed tomography (CT) imaging features among pulmonary nodules in patients who had undergone video‐assisted thoracoscopic surgery (VATS) lobectomy from 2013 to 2018. Preliminary selection of features was based on a statistical analysis using SPSS. We used WEKA to assess the machine learning models using its multiple algorithms and selected the best decision tree model using its optimization algorithm. Results The combination of decision tree and logistics regression optimized the decision tree without affecting its AUC. The decision tree structure showed that lobulation was the most important feature, followed by spiculation, vessel convergence sign, nodule type, satellite nodule, nodule size and age of patient. Conclusions Our study shows that decision tree analyses can be applied to screen individuals for early lung cancer with CT. Our decision tree provides a new way to help clinicians establish a logical diagnosis by a stepwise progression method, but still needs to be validated for prospective trials in a larger patient population.
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Affiliation(s)
- Si-Qi Liu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiao-Bin Ma
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wan-Mei Song
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yi-Fan Li
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ning Li
- Shandong Medical Imaging Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Li-Na Wang
- Department of Medical Imaging, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jin-Yue Liu
- Department of Intensive Care Unit, Shandong Provincial Third Hospital, Jinan, China
| | - Ning-Ning Tao
- Department of Respiratory and Critical Care Medicine, Beijing Hospital, Beijing, China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shi-Jin Li
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ting-Ting Xu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qian-Yun Zhang
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qi-Qi An
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bin Liang
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Huai-Chen Li
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, China
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Abstract
The increasing use of low-dose CT for screening for lung cancer will inevitably identify many small, asymptomatic lung nodules and ground-glass opacities (GGOs). Current guidelines for the management of screening-detected lesions tend to advise a conservative approach based on serial imaging and intervention only if ‘suspicious’ features emerge. However, more recent developments in thoracic surgery and in the understanding of the screening-detected lesions themselves prompt some pertinent questions over this conservatism. Is CT surveillance sufficiently reliable to exclude malignancy? Is it really necessary to hold back on operative biopsy and resection given modern surgical safety and efficacy? Is the option for early surgical therapy a viable one—especially with the availability of sublobar resection today? Modern data suggests that the risk of inaction for some screening-detected lesions may be higher than expected, whereas the potential harm of surgical intervention may be substantially reduced by sublobar resection and the latest minimally invasive surgical techniques. A more pro-active approach towards offering surgery for screening-detected lesions should now be considered.
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Affiliation(s)
- Alan D L Sihoe
- Gleneagles Hong Kong Hospital, Hong Kong, China.,International Medical Centre, Hong Kong, China
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9
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Kodia K, Razi SS, Stephens-McDonnough JA, Szewczyk J, Villamizar NR, Nguyen DM. Liposomal Bupivacaine Versus Bupivacaine/Epinephrine Intercostal Nerve Block as Part of an Enhanced Recovery After Thoracic Surgery (ERATS) Care Pathway for Robotic Thoracic Surgery. J Cardiothorac Vasc Anesth 2021; 35:2283-2293. [PMID: 33814245 DOI: 10.1053/j.jvca.2021.02.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/26/2021] [Accepted: 02/28/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To examine how postoperative pain control after robotic thoracoscopic surgery varies with liposomal bupivacaine (LipoB) versus 0.5% bupivacaine/1:200,000 epinephrine (Bupi/Epi) intercostal nerve blocks within the context of an enhanced recovery after thoracic surgery (ERATS) protocol. DESIGN A retrospective analysis of a prospectively maintained database of patients undergoing robotic thoracoscopic procedures between September 1, 2018 and October 31, 2019 was conducted. SETTING University of Miami, single-institutional. PARTICIPANTS Patients. INTERVENTIONS Two hundred fifty-two patients had either LipoB intercostal nerve blocks (n = 129) or Bupi/Epi intercostal nerve blocks (n = 123) when undergoing robotic thoracic surgery. MEASUREMENTS AND MAIN RESULTS Comparative analysis of patient-reported pain levels, in-hospital and post-discharge opioid requirements, 90-day operative complications, length of hospital stay, and hospital costs was performed. Data were stratified to either anatomic lung resection or pulmonary wedge resection/mediastinal-pleural procedures. Bupi/Epi patients reported significantly more acute postoperative pain than LipoB patients, which correlated with higher in-hospital and post-discharge opioid requirements. There were no differences in postoperative complications, length of hospital stay, or hospital costs between the two groups. CONCLUSIONS As part of an ERATS protocol, infiltration of intercostal spaces and surgical wounds with LipoB for robotic thoracoscopic procedures afforded better postoperative subjective pain control and decreased opioid requirements without an increase in hospital costs as compared with use of Bupi/Epi.
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Affiliation(s)
- Karishma Kodia
- Section of Thoracic Surgery, the DeWitt Daughtry Department of Surgery, University of Miami, Miami, FL.
| | - Syed S Razi
- Division of Thoracic Surgery, Memorial Healthcare System, South Broward, FL
| | - Joy A Stephens-McDonnough
- Section of Thoracic Surgery, the DeWitt Daughtry Department of Surgery, University of Miami, Miami, FL
| | - Joanne Szewczyk
- Section of Thoracic Surgery, the DeWitt Daughtry Department of Surgery, University of Miami, Miami, FL
| | - Nestor R Villamizar
- Section of Thoracic Surgery, the DeWitt Daughtry Department of Surgery, University of Miami, Miami, FL
| | - Dao M Nguyen
- Section of Thoracic Surgery, the DeWitt Daughtry Department of Surgery, University of Miami, Miami, FL
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10
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Haywood N, Nickel I, Zhang A, Byler M, Scott E, Julliard W, Blank RS, Martin LW. Enhanced Recovery After Thoracic Surgery. Thorac Surg Clin 2020; 30:259-267. [DOI: 10.1016/j.thorsurg.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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11
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Survival After Thoracoscopic Surgery or Open Lobectomy: Systematic Review and Meta-Analysis. Ann Thorac Surg 2020; 111:302-313. [PMID: 32730840 DOI: 10.1016/j.athoracsur.2020.05.144] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/10/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Video-assisted thoracoscopic surgery (VATS) has been shown to reduce hospital stays and pain compared with open lobectomy to treat non-small cell lung cancer. Because of the low rate of deaths, it is difficult to show differences in survival in individual studies. The objective of this study was to compare short- and long-term mortality by means of a systematic review and meta-analysis. METHODS The reviewers systematically searched studies that compared VATS vs open lobectomy and provided data on 30-day mortality or long-term survival (>5 years). For long-term outcomes, studies included patients with the same cancer stage or, if several stages were included, the studies had to control for cancer stage in their propensity score model. A pooled odds ratio and hazard ratio (HR) was respectively calculated for short- and long-term outcomes. RESULTS A total of 33 works were identified, comprising 61,633 patients. VATS led to lower postoperative mortality (odds ratio, 0.64; 95% confidence interval [CI], 0.56 to 0.73) and higher long-term survival (HR, .88; 95% CI, 0.81 to 0.96). Disease-free survival was similar in both groups (HR, 0.94; 95% CI, 0.80 to 1.10). CONCLUSIONS For non-small cell lung cancer treated with lobectomy, VATS was associated with lower postoperative mortality and greater long-term survival compared with open lobectomy. Disease-free survival was similar between both groups.
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Commentary: Video-assisted thoracic surgery in the era of enhanced recovery after surgery—does good perioperative care trump good surgery? J Thorac Cardiovasc Surg 2020. [DOI: 10.1016/j.jtcvs.2019.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Commentary: Revisiting old data: Is video-assisted thoracoscopic surgery still superior to thoracotomy when enhanced recovery is applied? J Thorac Cardiovasc Surg 2020; 159:297-298. [PMID: 31627954 DOI: 10.1016/j.jtcvs.2019.08.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 11/20/2022]
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Flores RM. Commentary: Minimally invasive thoracic surgery lobectomy: Truth versus hype. J Thorac Cardiovasc Surg 2019; 159:295-296. [PMID: 31627953 DOI: 10.1016/j.jtcvs.2019.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Raja M Flores
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY.
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